assuming one could create the needed software and have a staff of the absolute minimum humans… could the American healthcare system be fixed using computer initiated transfers and claims processing and eliminating 90 percent of the “waste” in having humans monitor algorithms?
noted that this would theoretically be the case in many industries but since HI is such a big deal and so numbers based…
What algorithm would you use to determine fraudulent claims?
Is there a reason you think insurance companies aren’t automating every step they possibly can? The manual processes involved are there for a variety of reasons and any time you see one, it’s there because no one has figured out how to automate it without some unwanted side effect.
I have one good example from military billing practices. At one point about ten years ago, the US military was criticized for spending too much time reviewing fulfillment orders going to Iraq (or other active combat zones). “Troops are dying without their gear!” is a pretty convincing complaint. So the military implemented a process that automatically paid every order marked for combat zones, with the normal review happening after the fact. A military supplier (two women in Florida) figured this out and got $20 million in bogus payments rushed through. They were caught eventually, but not before the money was spent. If memory serves, the government thought it would recover about $4 million by seizing boats and houses.
I guess that adding an “in a perfect world” disclaimer to the OP would have been a good idea. Could an algorithm be developed to suit the needs, considering the programmer was a Jonas Salk type who would just turn his financial solution loose?
IMHO, a program could do a much, much fairer and more cost-effective job than any bureaucracy.
For example, AI could determine at what age certain procedures are a waste of money, and never approve them. With humans involved, people will always try to get any treatment possible, no matter how expensive. A program could make decisions unaffected by emotion.
Of course, nobody would stand for it…
Didn’t the NHS system tried to do something like that- putting a benefit to cost ratio on medical procedures and setting a go/no go threshold, which led to a lot of people complaining and such outcomes as Visudyn treatment for one eye but not both?
As far as insurance automation, I work at an insurance company, and the cutthroat competition has led us to automate everything possible- the overwhelming majority of claims payment is automated now. The trouble is that Cobol programmers don’t come cheap so it’s a manner of weighing their time vs cheap claims processors (partially even being outsource to India).
We were actually not sad to see lifetime maximums and pre-exist go, they were extremely labor intensive and thus error prone. Pre-exist sometimes got our appeals department, high priced staff of nurses and staff physician involved and we had to manually process every claim during the pre-exist period; lifetime involved pulling microfilms from many years back and adding it all up with Excel spreadsheets and again reviewing every claims. We offered them because every other company did and thus we would be at a competative disadvantage if we were the only one not to.
A problem is the sales doesn’t talk with the technical people, so they write benefits (sometimes on their own intiative, sometimes at the insistance of HR) that our automation can’t handle. Obamacare should help this, although it’s yet another set of benefits to load they are much simpler and more standardized. Sales is now going to have incentives for customers picking policies that are automation friendly and in the long term we will be scrapping the COBOL systems.
No. The insurance companies are entirely ‘waste’ in the healthcare system – they do not provide any ‘health care’ to anyone. They are just parasites compared to the doctors, nurses, pharmacists, etc. who actually do take care of people.